Page 2607 - Saunders Comprehensive Review For NCLEX-RN

seizures, and visualize this clinical situation. Recalling that airway patency and
safety are the priorities will assist in determining the correct interventions.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Pediatrics: Neurological
Health Problem: Pediatric-Specific: Seizures
Priority Concepts: Intracranial Regulation; Safety
Reference: McKinney et al. (2018), pp. 1299, 1301.

917. Answer: 1, 2, 3

Rationale: Nocturia, incontinence, and an enlarged prostate are characteristics of
BPH and need to be assessed for in all male clients over 50 years of age. Nocturnal
emissions are commonly associated with prepubescent males. Low testosterone
levels (not BPH) may be associated with a decreased desire for sexual intercourse.
Test-Taking Strategy: Focus on the subject, characteristics of BPH. Thinking about
the pathophysiology associated with this disorder will assist you in answering
correctly.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Renal and Urinary
Health Problem: Adult Health: Renal and Urinary: Obstructive problems
Priority Concepts: Clinical Judgment; Elimination
Reference: Lewis et al. (2017), p. 1269.

918. Answer: 1

Rationale: Setting priorities means deciding which client needs or problems
require immediate action and which can be delayed until a later time because they
are not urgent. Client problems that involve actual or life-threatening concerns are
always considered first. Although completing care in a reasonable time frame, time
constraints, and obtaining needed supplies are components of time management,
these items are not the priority in planning care for the client, based on the options
provided.
Test-Taking Strategy: Note the strategic word, priority. Recall the principles
related to prioritizing to answer the question. Noting the words life-threatening in the
correct option will assist in directing you to this option.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management: Prioritizing
Health Problem: N/A
Priority Concepts: Care Coordination; Clinical Judgment
Reference: Potter et al. (2017), pp. 241, 284-285.

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